INSR ADDL SUBR
LTR INSR WVD
DATE (MM/DD/YYYY)
PRODUCER CONTACT
NAME:
PHONE FAX
(A/C, No, Ext): (A/C, No):
E-MAIL
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
INSURER(S) AFFORDING COVERAGE NAIC #
Y / N
N / A
(Mandatory in NH)
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$
PROOTHER:
JECT LOC
COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS
AUTOS ONLY
HIRED PROPERTY DAMAGE $
AUTOS ONLY (Per accident)
$
OCCUR EACH OCCURRENCE $
CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
PER OTHSTATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ POLICY
NON-OWNED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
Transportation Insurance Company
Continental Insurance Company
Continental Casualty Company
Midwest Employers Casualty Company
Westchester Surplus Lines Insurance Co.
05/04/2023
USI Insurance Services, LLC CL
One SeaGate, Suite 1800
Toledo, OH 43604
419 243-1191
Jennifer Lake, CISR
419 392-6429
[email protected]
Midwest Tape, LLC
P.O. Box 820
Holland, OH 43528-0820
20494
35289
20443
23612
10172
A
A
X
X
OH Stop Gap
$1mi/$1mi/$1mi
X
X
X
X
6071847392
6071847392
05/09/2023
05/09/2023
05/09/2024
05/09/2024
1,000,000
500,000
15,000
1,000,000
2,000,000
2,000,000
A
X
X X
X X 6071847408 05/09/2023 05/09/2024 1,000,000
B X X
X 0
X X 6071847425 05/09/2023 05/09/2024 15,000,000
15,000,000
C
E
N
X
X
WC671847411
EWC009148
05/09/2023
05/09/2023
05/09/2024
05/09/2024
X
1,000,000
1,000,000
1,000,000
E Tech E&O/Cyber X X F15620304004 05/09/2023 05/09/2024 $5,000,000/$100k ret For Operations of Named Insured
For Information Only
1 of 1
#S39990235/M39990230
Client#: 1400052 MIDWETAP1
JALAH
1 of 1
#S39990235/M39990230
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